Tips on Retina Practice

Tips
on
Retina
Practice

Dr Sanjay Ahuja
Dr Jatinder Bali

Tips on Retina Practice

Fifth edition, 2022.
Copyright © [Sanjay Ahuja and Jatinder Bali, 2022]
First published 2022 by Ojasvini Bali

Edited and typeset by O Bali
The right of Sanjay Ahuja and Jatinder Bali to be identified
as the author of this work has been asserted in
accordance with the Copyright, Designs and Patents Act,
1988.
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in
any form or by any means (electronic, mechanical,
photocopying, recording or otherwise), without the prior
written permission of the publisher. This publication is
designed to provide accurate and authoritative
information. It is sold under the express understanding
that any decisions or actions you take as a result of
reading this book must be based on your judgement and
will be at your sole risk. The author will not be held
responsible for the consequences of any actions and/or
decisions taken as a result of any information given or
recommendations made.

ABOUT THE
AUTHOR

Dr. Sanjay Ahuja did his MBBS from

UCMS/ Safdarjang Hospital /Delhi

University/1980Batch (joining). He

completed MD Ophthalmology from RPC,

AIIMS in 1990. & then Senior Residency in

Retina unit from RPC (AIIMS) (1990-93)

under Prof Khosla, Prof Tiwari, Prof Atul

Kumar & Dr. Lalit Verma. He worked as a

Part time Retina consultant at MM EyeTech

(Lajpat Nagar) with Prof Madan Mohan, Dr.

Rishi Mohan & Dr. Indira Mohan from 1993

to 2007). He ran his private clinics at

Parmanand Colony (Mukherjee Nagar) &

Vijay Nagar (Near Delhi University) from

1993-2011 which have now been expanded

into a four storey Eye Nursing Home at

Parmanand Colony (Mukherjee Nagar) with

his wife, Dr. Aparna Ahuja, who is also an

Ophthalmologist from RPC/AIIMS (1990

batch joining). Dr Ahuja is currently

working as:

1. Visiting Prof of Ophthalmology (Guest
Teacher) at Dr. Sur Homeopathic Medical

College (SHMC) at Moti Bagh, IP
University, Delhi Govt.

2. Head of Ophtha Deptt at Sant Nirankari
Mandal (SNM) Charitable hospital at
Nirankari Colony, Delhi-9.

3. Honorary senior consultant at Tirath Ram
Shah Hospital (Near Tis Hazari courts).

He is the co-author of 2 Books on Eye
Disorders for Laymen with Dr. Aparna
Ahuja. He received special cash prizes &
certificates from ICMR, Delhi (2005) &
Central Health Ministry, Govt. of India
(2008). He has authored over 50 articles in
Indexed & Non-indexed journals & Health
magazines.

Dr. Jatinder Bali Delhi

Edited, Proofed and Published by Dr
Jatinder Bali.

Preface to the Fifth
Edition

This booklet has been written by a retina specialist with
years of extensive experience after training from the
premier institute with a view to be useful to the
comprehensive, general ophthalmologists primarily and
may also help those involved in treating retinal diseases. It
is not meant to be the comprehensive textbook, rather
it’s an easily digestible booklet on tips and facts about
commonly encountered diseases in day to day ophthalmic
practice. The tips and tricks outlined in this text are not
often discussed or adequately emphasised in most text
books. It was initially started as a discussion and then
expanded into a full blown practice series. The suggestions
of converting it into a book would have robbed it of the
appeal and stupendous following that the discussion
generated on different online forums. You may already be
aware of this from those discussions but this book takes
away none of the charm of reading the tips compiled and
available on your mobile phones or tablets.

We hope you enjoy reading this. Suggestions and
feedback are welcome. Good feedback is even more
welcome.

Dr Sanjay Ahuja

Dr Jatinder Bali

Delhi-2022.



Preface to First
Edition

This book is the result of a very popular
series of tips discussed by a group of leading
retina practitioners. It is very difficult to
commit to paper the candid intangible
observations in practising the art and the
science of the subspecialty in
Ophthalmology.

Indeed, who could have done it better than
Dr Sanjay Ahuja, who is himself a leading
academician and practitioner.

Tomes have been written about the retina
but the books focussed on retinal practice on
ground are few and far between. This book
is unique because it handles the subject from
a totally practical standpoint. It would have
been easy to digress into the theoretical
aspects but Dr Ahuja is a very disciplined
writer and has demonstrated tremendous
control over keeping this book totally
focussed on practice.

We hope the readers find the book
interesting because in presenting it we have

taken risk and made a sincere effort to make
it a useful advisor.

We welcome your feedback.

Dr Jatinder Bali,

Author of “Pathological Ocular Angiogenesis and Macular
Edema in Diabetes” and “Basics of Biostatistics: A
Manual for Medical Practitioners”

MBBS, MS, WHO Fellow in Vitreo-Retina, MBA
(Operations Research)

Narela Polyclinic,NDMC
Formerly Asst DNB coordinator, Memb-Secy of
Institutional Ethics Committee and Nodal Officer
(Information Technology), Hindu Rao Hospital, Delhi
Chairman, Subcommittee on Information Technology,
Practice Automation and Clinical Information Systems of

Delhi Ophthalmology Society

Delhi.
2020

PRACTICAL TIPS
Retina

--Dr Sanjay Ahuja.

Tip-1
Cross sectional image of conventional OCT
scan is the B-Scan structural image.
Consider it in 2 parts-
1. Inner retina with 3 hyper reflective layers
(viz. From in to out- RNFL, IPL & OPL) is
primarily affected in retinal vascular
disorders e.g DR, CRVO..
2. Outer retina with 3 hyper reflective layers
(viz. From in to out- ELM, IS/OS junction
or Ellipsoid layer & RPE) is primarily
affected in ARMD, CSR...

Tip-2
In Macular OCT image- To know whether
correct FOVEAL cut has been obtained,
check that OPL (Outer Plexiform layer)
should join RNFL at one point in the foveal
pit.

Tip-3
In this COVID era, one may put the Cling
film over & around the lens (towards

patient‟s side) of Fundus camera, Lasers,
OCT or S/L without any significant
compromise in quality. The film may be
cleaned with alcohol swabs or changed for
every patient.

Tip-4
For proper evaluation of retinal diseases on
OCT scan, always take the black & white
(grey scale) printout. NOT the coloured
print.

Tip-5
In OCTA (OCT Angiography) no dye is
injected (hence non-invasive) to study the
retinal & choroidal vessels at various levels)
The role of dye is taken up by the moving
RBCs in capillaries.

Tip-6
To differentiate whether it‟s a Red-free
fundus photo (taken with green filter on
fundus camera) or Fundus Autofluorescence
photo (FAF), Look at the optic disc. It is
dark/black on FAF but white on Red-free.
On ICG also, disc is dark but white on FFA.

Tip-7
Neovascular Membrane in ARMD can occur
at 4 levels (OCT based) viz.
Type-1: Sub-RPE (Occult CNVM)

Type-2: Sub-Retinal (Classic CNVM)
Type-3: Intra-retinal (RAP or Retinal
Angiomatous Proliferation)
Type-4: is mixed type 1&2
Main treatment for all is Anti-VEGF Inj.,
however response to treatment & prognosis
varies with type.

Tip-8
While giving Intravitreal injection, always
point the needle towards the CENTRE of the
globe & never anteriorly, as it may damage
the lens. Never try to visualise the needle tip
while inside the globe. Always check his
counting finger vision on the table itself
before patient leaves the OT.

Tip-9
Tip-9
Always treat the Diabetic maculopathy first
before undertaking the cataract extraction, if
possible. Control DM, HT & Renal
condition. Do his FFA & OCT if possible. If
CMT is >300 micron, always give
Intravitreal Anti-VEGF Inj. Do focal laser if
required (for focal thickening outside FAZ).
Normal following is to undertake the
cataract surgery after about a week of
injection. However, if cataract surgery is not
really urgent, good metabolic control should
first be achieved along with stabilisation of

diabetic retinopathy, especially if patient has
been seen for the first time, as maculopathy
may still worsen.
Tip-10
Never label the child or young adult
complaining of B/L diminution of vision as
a malingerer, even if his clinical
examination is totally normal, as he may be
having Heredomacular dystrophy like
Stargardt‟s (F. flavimaculatus) or Cone
dystrophy. These have totally normal fundus
in early phases even though the patient is
definitely symptomatic. Get his ERG, EOG
& FFA.

Tip-11
Standard Fundus camera clicks upto 50
degrees(*) in one shot.
How much is 50*?
360*/75mm i.e equatorial circumference of
globe =4.8* (5*approx). Thus 1mm=5*
Optic disc diameter is 1.5mm= 7.5*
Distance between Temporal disc margin &
fovea= 15*
Wide Field camera clicks 50-100*
Ultra wide field camera (e.g. Optos) clicks
100-200* (i.e approximately 80% of retinal
surface)

Tip-12
In newborns, cornea is small & steep, hence
angle of viewing on Indirect
ophthalmoscopy has to be more vertical
rather than oblique unlike for adults.

Tip-13
ROP simplified.....
WHOM TO SCREEN....
1. Preterm born at< or = 34 weeks
2. Birth weight < or = 2000gm
3. >34 weeks, If risk factors associated
WHEN TO SCREEN...
1. At 3 weeks of birth, if GA is <27 weeks
2. At 4 weeks of birth, if GA is > or = 27
weeks
3. At least 1 exam before discharge from
nursery.
HOW OFTEN TO SCREEN....
1. Every 2 weeks if no ROP
2. 2 days-2 weeks depending on zone &
stage.
WHEN TO STOP SCREENING...
1. Till retina fully vascularised. Temporal
retina vascularises last.
2. ROP fully regressed
3. 40 weeks of post-menstrual age
(=GA+Chronological age) if no ROP; as
ROP almost never starts fresh after 40
weeks.
WHOM TO TREAT.....

1. All with PLUS disease (dilatation &
tortuosity of retinal vessels at post pole)
2. Stage-3 (extra retinal vascularisation)
3. APROP

Zone-1 (around disc) is the most dangerous
& Zone-3 (temporal retina) is the least.

Tip-14
Doing just OCT scan in Diabetic
maculopathy to pick up Central Macular
Thickening & giving Ivit Anti-VEGF Inj is
not enough. FFA or OCTA must be done to
look for macular ischemia (broken FAZ on
FFA), as it makes prognosis poor & is
unresponsive to any treatment. Anti-
VEGF‟s treat edema & not ischemia.

Tip-15....
Always click Red-free photo (with Green
filter) on fundus camera to view retinal
vasculature, retinal hges, RNFL defects &
ERM as these are visualised better. Even
pale lesions like drusen & exudates are seen
better.

Tip-16.....
OCTA images are „en-face‟ images (i.e.
facing forwards like standard fundus
images) & NOT cross-sectional like OCT
scans. Images are taken transversely at

different levels/layers called Segmentation -
done Automatically by machine or Manually
adjusted by operator on OCT scan image
which is displayed simultaneously)

Tip-17.....
To differentiate Post cataract extraction
CME & Diabetic Macular Edema (DME)-
Edema in the former is Centered
symmetrically around the fovea & there are
no associated hard exudates or other DR
changes. But both commonly coexist
making differentiation difficult. On FFA,
late disc leakage in CME may give a clue.
On OCT, edema first starts in superficial
retina in CME (entry of inflammatory
cytokines from vitreous), while in DME,
edema starts in deeper retina (breakage of
inner & outer blood retinal barriers). CME
generally resolves spontaneously in 80% in
3-12 months.

Tip-18.....
Eales‟ disease is a focal disease, only those
areas affected by disease need to be lasered
i.e. scatter laser only of ischemic/
neovascular areas; while Diabetic
retinopathy is a generalised retinal disease,
hence no role of focal/local laser (except in
maculopathy) & if laser has to be done, it
has to be full PRP & NOT the partial scatter

of ischemic/ neovascular areas or just
posterior pole scatter.

Tip-19.....
FFA tells about the activity of retinal disease
in form of dye leakage (i.e breakage of
blood-retinal barrier), while OCTA can‟t tell
whether neovascularisation is active or
regressed i.e. disease is now inactive.
Conversely, in OCTA, image doesn‟t get
obscured by dye leakage & hence clear
depiction of CNVM is possible unlike FFA.

Tip-20....
IRMAs vs Retinal Neovascularisation
(NV)....
IRMAs unlike NV are broader in calibre,
deeper in retina (hence have fuzzy margins
& burgundy (purplish red) in color (not red
of NV), don‟t occur on disc & don‟t leak on
FFA.
Both indicate ischemia.
IRMAs may form from preexisting
capillaries or new growths.
Posterior hyaloid or ILM breach on OCT
occurs only in NV.
IRMAs may act as precursors of NV after
they breach ILM & Posterior hyaloid.

Tip-21.....
On USG-B scan for proper posterior

segment evaluation, Always do Transverse
& Longitudinal scans Transconjunctivally
(unless globe open) under topical anesthesia.
In Transverse scan, mark on the probe is
kept parallel to limbus (perpendicular in
Longitudinal). Each quadrant of globe has to
be scanned systematically. In each quadrant,
go from limbus to fornix while patient
moves his eyes in other direction.
Area in mark‟s direction is always projected
superiorly in monitor.
Axial scan may be done transpalpebral & in
the last.

Tip-22.....
Excessive retinal venous „tortuousity‟ is the
most important characteristic of venous
occlusions (even if impending). No other
common disease affecting retinal veins
causes it, whether it be severe NPDR (cause
venous dilatation, beading & looping),
Ocular ischemic syndrome or hypertensive
retinopathy. Rare exceptions are- Congenital
venous tortuousity, Feeder venule of retinal
capillary angioma & other angiomas, Sickle
cell retinopathy.

Tip-23.....
Ellipsoid layer (IS/OS junction) if damaged
on OCT scan indicates poor visual prognosis
in retinal diseases. Ellipsoid layer is hyper

reflective layer in outer retina just inner to
RPE & COST layers but outer to ELM.

Tip-24.....
Never fail to record BP in any patient with
bilateral disc edema & retinal hges around
the disc (Malignant HT)

Tip-25.....
In ischemic CRVO, Explain the poor visual
prognosis clearly & risk of developing NVG
(in 30%, in 1-6 months). Do OCT & give
anti-VEGF/Ozurdex for CMT of >300
micron. Followup every month for
NVI/NVA & fundus & OCT for CMT. If
NVI/NVA developing, do PRP if feasible.
Good quality FFA is possible only after 6
months.

Tip-26.....
Good fundus photo is the one which is
evenly illuminated & focussed from edge to
edge.

Tip-27.....
In Ophthalmic artery obstruction, vision is
even worse than CRAO, almost PL negative
& Cherry red macula is not seen, because
Ophthalmic artery serves both Retinal
circulation (via CRA) & Choroidal

circulation (via Posterior ciliary arteries
which supply choroid, outer 1/3rd retina &
even optic disc.) Fovea has only outer 1/3rd
retina.

Tip-28.....
VKH may sometimes be confused with
CSR(CSC). Both cause serous RD. Very
important to differentiate as VKH needs
systemic steroids which are contraindicated
in CSR.
In VKH unlike CSR, Retrolental/ vitreous
inflammatory cells are there. On FFA in
VKH, leaks are multiple & fill serous RD
fully, disc being hyperemic, also stains in
late phases. Neurosensory retinal
detachment area NEVER fills completely
with dye in CSR.
Tip-29.....
PACHYCHOROID (literally Thick choroid,
Subfoveal choroid of >300 mn), becomes
„Pachychoroid disease‟ (P) if assd. with 3
features viz.
1. Attenuation of choriocapillaris.
2. Dilated choroidal vessels (outer Haller‟s
layer).
3. Progressive RPE atrophy &
Neovascularisation.
P. has many variants (more being added &
includes CSC/CSR, PCV, etc.) which have
„common Pathogenecity‟.

P. is a new concept (2013) which came after
choroidal imaging became easy with EDI
(Enhanced Depth Imaging) OCT & SS
(Swept Source) OCT. Both use longer
wavelength than conventional OCTs, thus
penetrating deeper with reduced scattering
& signal loss.

Tip-30....
+90D fundus exam. steps...
Theoretically field of view is 70 degrees
(d),practically 35d only.
Use 2-3 mm width of S/L.
Aim light source prependicular or 10d off-
axis.
Place lens 1/2 inch from patient‟s eye.
Pull back Joystick while looking through
S/L till beam focused on retina.
Make finer adjustments.
Keep drawing chart „upside down‟ while
noting findings (inverted image).

Tip-31.....
In PRP, laser spots should be greyish white
(NOT dense white) ie moderate intensity,
1.5-2 burns width apart (spots auto-expand
leaving 1-1.5), avoiding major retinal
vessels, old laser spots, chorioretinal scars,
retinal hges & vortex veins. Treat inferior
areas first (may get obscured by future
bleed). With 200-250 mn spot size (larger

spots cause more pain, as it needs greater
power), PRP needs 2500-3000 spots for
completion.
Tip-32......
No leak on FFA in CSC/CSR (although SRF
still present) may indicate:
1. Resolving CSC
2. Rule out „Optic nerve pit‟- depression in
nerve which has a totally „different color‟
from optic nerve (neither pink nor
white/pale). It is grey, black or even yellow,
because of glial tissue.

Tip-33.....
On OCT scan print, to know whether it is
the Right or Left eye..... RNFL is much
thicker towards the disc. Hence if RNFL is
thicker on our left side, it is the left eye
image.

Tip-34.....
Unexplained (on clinical examination) deep
seated U/L eyeache without proptosis but
with ocular tenderness is highly suggestive
of Posterior Scleritis (PS). Although rare, it
is the most frequently missed or
misdiagnosed eye disease.
In PS, Inflammation is posterior to insertion
of Recti i.e. Ora serrata. Associated with
systemic immune diseases. Choroid, retina
& optic nerve may get associated

inflammation. USG B Scan is Typical. (Tip-
35).

Tip-35.....
T- Sign on USG-B Scan is typical (almost
pathognomonic) of Posterior Scleritis. Thick
sclera of >2mm (along with thick choroid &
fluid/edema in Tenon‟s capsule) forms
horizontal limb of T. Vertical limb of T is in
optic nerve (surrounding edema). T is
echolucent (dark/black) on USG.

Tip-36.....
Is it T-1 or T-2 on MRI Scan?
Remember T-2 loves H2O (water), hence
cavities filled with water (liquid) eg
Vitreous & CSF (in Ventricles) are white on
T-2. Opposite with T-1.
Fat, Melanin, blood & Aspergillus are
whiter on T-1, hence Dermoid, Lipoma,
Melanoma, Hgic Choroidal detachment &
fresh hge anywhere in eye (3-14 days old) &
Aspergilloma are whiter on T-1.
Contrast (Gadolinium) makes everything
more white on T-1, hence Fat-suppression
must to study orbital diseases properly.
T-1 delineates Normal anatomy better,
hence grey matter of brain is grey on T-1 &
white matter is white. All opposite with T-2.

Tip-37......
Brolucizumab (Beovu, Novartis) is the latest
Anti-VEGF approved by US-FDA
(October‟19) for wet AMD. Dosing interval
is much longer (12 weeks), although 3 initial
monthly loading doses recommended. Cost
is ~1850$ (1.4 lakh INR). Not available in
India.

Tip-38......
Laser Retinopexy/Barrage laser....
Laser spots are placed 1/2 burn width apart
(become confluent with spread of laser
burn). 3 rows are applied all around the
break. If small detachment is associated,
extend spots till Ora. Maximum attachment
strength is achieved in 2 weeks.

Tip-39......
Don‟t order EOG in very young children or
non-cooperative patients. EOG records
electrical potential difference between front
& back of eye, hence it requires patient to
move eyes from side to side (electrodes are
near inner & outer canthi) (15 minutes in
dark & light alternately).
EOG is the „best‟ for Best‟s disease
(affected even in early stage also), while
only in advanced stage in Stargardt.
Normal value (Arden ratio > or = 1.8).
Arden ratio term is now replaced by new

(2017) term- „Light peak:dark trough ratio‟.

Tip-40.....
In a case of Rubeosis with a few retinal
hemorrhages, especially in mid-periphery,
no or minimal venous tortuousity & no disc
edema (unlike CRVO) ALWAYS think of
Ocular Ischemic Syndrome. OIS occurs with
>70% obstruction in Carotid/Ophthalmic
artery. Usually U/L (unlike DR). Do FFA &
PRP. Refer to physician & get Carotid
Doppler (may need Endarterectomy). CRA
perfusion pressure is low.

Tip-41.....
OCT Angiography (OCTA) printout
basically shows 4 kinds of images....
1. Fundus image (Enface structural image
like any fundus photo)
2. Conventional OCT scan image (it is cross
sectional- both horizontal & vertical)
3. OCT scan image showing Segmentation
levels for OCTA scans, either Automatic by
machine or Operator adjustable /Scrolled-
depending upon area of interest.
4. OCTA Segmented scan images
(Enface/frontal view) which grossly show 4
levels of Vascular planes viz.
i) Superficial capillary plexus (RNFL/GCL
level)
ii) Deep capillary plexus (IPL & INL)

iii) Avascular (outer retina-
ONL/ELM/Photoreceptor/RPE). Any
vascularity at this level is
Neovascularisation/abnormal.
iv) Choriocapillaris

Tip-42.....
If both Diabetic maculopathy (DDME) &
PDR are present together (commonly
happens), always treat Macular edema first
by giving Anti-VEGF, followed by PRP
starting after a week, as laser aggravates
edema.
If patient has both central DDME & focal
edema little away with focal leak (from
microaneurysm or capillaries). In addition to
giving Anti-VEGF, focal laser should be
done for this focal leak.

Tip-43......
3 most common causes of CNVM are:
1. AMD
2. Pathological Myopia- CNVM is small,
type-2 (ie subretinal/ beneath NSR)
minimally leaking & is closer to fovea.
Foveal hge doesn‟t always mean CNVM.
3. Idiopathic- usually of classic variety (ie
subretinal again).
Treatment of choice for all is Anti-VEGF,
however last 2 have much better prognosis
than AMD.

Tip-44......
Intraretinal cystic hyporeflective spaces on
Macular OCT may indicate CME or ORT
(Outer Retinal Tubulation). VERY
important to differentiate as the latter needs
no treatment, while CME (eg in DR,
AMD..) may need AntiVEGF.
ORT unlike CME has typical thick Hyper-
reflective borders around cystic space & is
located only in ONL of retina & CMT
(central macular thickness) may be normal.
ORT indicates chronic retinal disease
(photoreceptors get folded outward, ie
towards RPE) eg in n-AMD, HMD, diabetic
maculopathy, etc. ORT indicates poor visual
prognosis.
Both CME & ORT may coexist.
Optical coherence tomography showing
outer retinal tubulation (indicated by white
arrowhead) in a case of neovascular age-
related macular degeneration. White arrow
indicates intraretinal cyst. Black arrow
indicates subretinal fluid. Pic taken from
Internet.

Tip-45......
On FFA, In transmitted hyperfluorescence
(ie window defect) hyperfluorescence starts
in early phase, increases slowly but fades in
Later phases unlike hyperfluorescence of

leakage/ staining or pooling (eg in active
CNVM, Leak of CSC, NVD/NVE, PED)
which increases in later phases.
For hypofluorescent areas, always look at
Fundus photo to differentiate CNP
(Capillary non-perfusion) areas from
Blocked fluorescence. Latter matches with
extent of blocking material (eg hge).
Moreover, CNP areas have normal capillary
outlining unlike blocked fluorescence.

Tip-46.......
It‟s important to differentiate AMD from
PCV (Polypoidal Choroidal Vasculopathy)
as the latter has much better prognosis (if
detected & treated early) with combined (as
per EVEREST study) Anti-VEGF (treats
fluid) & PDT (treats BVN & Polyps), while
AMD has much poorer prognosis.
PCV- has Multiple „sero-sanguinous PEDs
& hard exudates‟ (neovascular & Hgic
disease) in old age (50-65 years).
Commoner in Asians. Mimics type-1 AMD
(sub-RPE/occult CNVM). Question whether
PCV is a variant of AMD is unsettled?
Polyp & abnormal BVN (Branching
choroidal Vascular Network) are
pathognomonic features arising from inner
choroidal vasculature (cause ?).
Unlike AMD, PCV has/is....
1. No associated druse.

2. More often peripapillary or multifocal
(Macula more commonly involved in
Asians)
3. Anti-VEGF alone are not effective unlike
in AMD.
3. Fundus: Reddish-orange round polypoidal
lesions seen (if large).
4. Retinal hemorrhage is generally „large‟.
5. FFA- only occasionally detects polyps.
Basically to rule out other causes of
exudation & CNVM.
6. OCT- Polyps seen as elevation from RPE-
Bruch‟s. Cystic spaces less common (hence
better prognosis than AMD). „Double layer
sign‟ is characteristic at PED margins
(separation of Bruch‟s from either RPE or
choroid).
7. ICGA is MUST & confirmatory. Polyps
at termination of BVN seen better in mid
phases with fading centre or late staining or
leaking walls in late phases.

Tip-47.....
Characteristic FFA picture in common Optic
nerve diseases....
1. Optic pit- Early hypofluorescence & late
staining of pit, because of absence of vessels
but presence of glial tissue in pit.
2. Papilledema- Disc capillaries dilated &
leaking. Late staining of disc.

3. AION- Differential disc capillary filling
in superior & inferior half.
4. Disc drusen- Autofluorescent before dye
injection. Late staining
5. Neuroretinitis- Dilated & leaking disc
capillaries. Macular fan/star is from leakage
of disc capillaries & NOT macular
capillaries.
6. Leber‟s hereditary optic neuropathy-
Dilated disc capillaries bot NOT leaking.

Tip-48.....
How to identify RNFL defects on Fundus
exam....
1. Normal RNFL is brighter & has striations
(stripy textured pattern). Brightness &
striations reduce with damage.
2. Observe parapapillary vessels. Typically,
they appear fuzzy. With RNFL damage/loss,
their borders become more defined.
About RNFL defects on fundus exam....
1. Not specific to glaucoma (any optic
neuropathy/ ganglion cell loss) can cause
them.
2. Better seen in Red free photos (green
filter).
3. Occur more often in NTG & early rather
than advanced glaucomas.
4. Could be localised wedge shaped or
diffuse. Former is easier to identify than
diffuse.

5. Associated disc hge common (in wedge
defects).
6. Commoner in superior & inferior
temporal regions.
7. Help in pre-perimetric diagnosis of
glaucoma.

Tip-49......
Typically, early postoperative
endophthalmitis unlike non-infective (eg
TASS- starts earlier-within 24 hours, limbus
to limbus cornea edema, no posterior
segment involvement, responds to steroids)
is characterised by- pain (most significant
but missing in 1/4th), lid edema, congestion,
chemosis & more AC reaction as compared
to that expected by surgeon (For treatment,
see Tip-50).
Chronic postop endophthalmitis (presenting
after 6 weeks) is mostly caused by
Propionibacterium acnes followed by Fungal
or Staph albus. Pain & inflammation may
respond to steroids initially but recurs
requiring Intracapsular Vanco, Radical PPV
with capsule & IOL removal.

Tip-50......
Management of early (<6 weeks) Post-
cataract endophthalmitis (Es). Broad
outlines....
1. Always consider Es, if early postoperative

patient calls U c/o PDR ie Pain, D/V &
Redness.
2. Western literature says organisms in 90%
are Gram +ve bacteria (70% Coagulase-ve
Staph ie albus). Indian studies blame Gram -
ve equally.
3. Look at the Disc & Retinal vessels &
grade Fundal glow with I/O (Whether both,
only disc or none seen) for follow ups.
4. Take anterior vitreous needle tap (26 G
with TB syringe, 3.5 mm from limbus)
slowly. If dry, take vitreous biopsy with
cutter.
Gram stain & c/s (preferably for all 3-
aerobic, anaerobic & fungal). For PCR,
inform lab about suspected organism(s).
5. IVit inj of Vancomycin (1mg in 0.1ml) &
Ceftazidime (2.25mg in 0.1 ml) separately,
3.5 mm from limbus. or Amika (0.4mg in
0.1ml) instead of Cefta.
6. Moxifloxacin & Concd Tobra (1.4%, 5ml
of 0.3%Tobra + 2ml of 80mg Tobra Inj)
eyedrops every 1 hourly. Homide/Atropine.
Anti glaucoma, if required. Start Topical
steroids after 24-48 hours if condition stable/
improving (Not if fungal suspected)
7. IV Ciprofloxacin (200mg BDx 2 days)
followed by oral 750mg BD x10 days. Cipro
more broad spectrum than Moxi. Moxi more
effective against MRSA Staph but less
against Gram-ve.

8. Repeat IVit Inj at 48 hours if condition
stable but no significant improvement. If
deteriorated, go for PPV.
9. Improvement means Symptoms reduced,
less AC reaction & glow improved.
10. As per EVS (Es Vitrectomy Study), Go
for early PPV, if VA is only PL.
11. EVS applicable to early postop Es only
& NOT to Chronic (>6 weeks) postop, post
traumatic or endogenous Es.
12. Treat wound leak, vitreous incarceration,
etc if any.
13. Coagulase-ve Staph has better prognosis
than Coagulase +ve Staph & Gram -ves (eg
Pseudomonas).
14. Prognosis worse with post IVit Inj Es
(organism‟s direct entry into vitreous).

Tip-51....
Non-contact Fundus biomicroscopy.....
1. S/L can‟t show beyond anterior 1/3rd of
eye as cornea acts as high plus lens (i.e.
converges), another plus lens placed before
it, makes it an astronomical telescope.
2. Powers used... +60 to +130D (commonly
+78 & +90D). Give real, Inverted &
laterally reversed aerial image.
3. With increasing power of lens...
i) Working distance from cornea decreases.
ii) Magnification decreases
iii) Field of view increases.

iv) Work better even with smaller pupil
Eg +90D provides 74* static (dynamic is
when patient is asked to move the eyes to
increase the field) field, 0.76x magnification
& 7mm working distance from cornea
unlike +60D (68*/1.15x/13mm).
4. +60D is for detailed disc exam & 90D is
„Harfan-maulla‟). Buy 90D if cheap, single
lens inventory planned.
5. Volk also makes Branded lenses like
„Superfield‟ (95*/0.76x/7mm) & „Digital
wide field‟ (103*/0.72x/4.5mm). Digital
(HD/High Definition) lenses have improved
shapes & high index glass. They are the best
buys but costlier.
6. Optics of S/L also matters.
7. Single use (disposable!) lenses also now
available.

Tip-52.....
Hyper reflective lesions on OCT Macula
are- 4H‟s.. Heme (blood), Hard exudates,
Healed scars & Hyperpigmentation. Also
Neovascularisation.
Hyper reflective lesions appear red on
colored scan & white on grey scale.

Tip-53......
Preretinal hemorrhage (hge) term is loosely
used for both „Subhyaloid hge‟ (SHH i.e.
under posterior hyaloid) & „Sub-ILM hge‟

(SIH), although SIH is Intra & not
preretinal.
Clinical differentiation is difficult, but may
be possible.....
SIH unlike SHH has....
1. Glistening reflexes from ILM on
fundoscopy.
2. Sharply demarcated & dome shaped.
3. Doesn‟t change position with change in
head posture.
4. More often Macular.
5. OCT of upper clearer area in patients with
partial PVD, 2 distinct hyper reflective
membranes may be seen (of ILM &
Posterior hyaloid membrane).
6. Takes longer to absorb.
7. Less safer to do „YAG posterior
hyaloidotomy‟. Normally done with 3-
mirror near inferior edge of hge away from
vessels & fovea; start with 5 mJ, increase by
1 mJ till perforation visible.
8. Needs surgery more often.
9. Definite differentiation may be possible
only during Vitrectomy & ILM staining.

Tip-54......
In a patient with simultaneous pre retinal,
Intraretinal & subretinal hemorrhage, always
think of Retinal Artery Macroaneurym
(RAM). Hge is NEVER subretinal in DR.
RAM is/has...

1. Acquired, focal, aneurysmal dilatation of
usually temporal 2nd order retinal arteriole.
2. Average size =200mn (Microaneurysm
=10-50 mn)
3. Associated HT common (75%).
4. May leak (edema & exudation) or rupture
(hge at ANY retinal level).
5. Treatment- Observe, if asymptomatic
(spontaneous resorption common). Direct
Laser (large spot size) or Anti-VEGF. For
submacular hge- PPV, pneumatic
displacement +/- TPA.

Tip-55.....
In a case of Retinal vasculitis, ALWAYS
check, which vessels are mainly involved...
1. Phlebitis (venous)- in Eales, Behcet‟s,
TB, Sarcoid, Pars planitis, Multiple
sclerosis, HIV.
2. Arteritis- in ARN (Acute retinal necrosis
in HSV or HZV), Systemic vasculitides/SV
(SLE, PAN, Wegner) & Idiopathic.
If associated fundus finding in vasculitis is...
1. Cotton wool spots- think of SV
2. Necrotising retinitis- Toxoplasmosis,
ARN, CMV.
3. Frosted (ice crystals like deposits on
vessel walls) branch angiitis- in Idiopathic,
Lymphoma or Leukaemic infiltrates, SV,
Toxoplasmosis, HIV & HSV.
4. BRVOs- in all causes of Phlebitis (vide

supra ut ante dictum est).

Tip-56......
Optic Nerve Head Drusen (ONHD) may be
confused as disc edema or Papilledema. To
differentiate on fundus exam. ONHD
is/has...
1. Pinkish or yellowish disc & NOT
hyperemic or having hemorrhages or
telangiectatic vessels.
2. Peripapillary nerve fibre striations are not
obscured.
3. Vessels of disc are not dilated & don‟t get
obscured as they traverse the disc margin.
4. Disc margins may have lumpy
appearance, if druse are superficial.
5. Spontaneous venous pulsations may be
present.
6. Edema is always superficial while druse
may be deep.
7. Usually asymptomatic.
8. Anomalies of overlying disc vessels are
common.
USG-B Scan is the most important
investigation for buried drusen, being seen
as highly echogenic foci (ONHD are
calcified extracellular axoplasmic proteins).

Tip-57......
Incidence of Lattice degeneration in
Degenerative/Pathological myopia (PM,

usually >-6D) is NOT more than in Simple
myopia. Posterior staphylomatous
elongation in PM rather than whole eye
enlargement doesn‟t increase chances of
Lattice.
Following changes occur only in PM...
1. Myopic crescent-Hallmark. Usually
temporal
2. Lacquer cracks in Bruch‟s. May cause
subretinal hge with or without CNVM.
3. Fuch‟s spot- submacular
hyperpigmentation indicating old hge or
CNVM.
4. PVD & RD.
5. Posterior staphyloma
6. Geographic/ chorioretinal atrophy in
posterior pole or anywhere in retina.
7. CNVM- Type-2/Subretinal/Classical.
May sometimes remain spontaneously
stable. Much better prognosis than in AMD.

Tip-58....
In some cases of CSC/CSR, there is large
neurosensory retinal (NSR) detachment of
posterior pole. This leads to gravitational
shift of fluid to inferior retina, ultimately
leading to „gutter‟ formation (RPE tracts) of
RPE alterations extending inferiorly to have
a flask, tear drop or dumb-bell shape.

Tip-59.....
When to treat Retinal Lattice degeneration
(LD)?...
LD with or without atrophic retinal holes per
se doesn‟t need any prophylactic treatment
except in special situations. As per AAO
recommendations (2019), these are..
1. Acute Symptomatic LD (fresh
flashes/floaters) with Horse shoe tears.
2. Acute PVD with vitreous/ retinal hge or
visible vitreo-retinal traction (on contact
fundus biomicroscopy)
However, most retina specialists treat in
following conditions also (although
controversial)....
1. LD in fellow eye of RD (Retinal
detachment).
2. Family h/o RD
3. Those undergoing cataract (increases
PVD chances, the main CULPRIT for
tears/RD in LD, because of strong
vitreoretinal adhesions at lattiice edges) or
LASIK surgery.
4. Poorly compliant patient
5. Those predisposed to contact traumas.
6. Associated SRF
7. Very large number of lattices, especially
if in superior quadrants
8. Radial and especially perivascular
lattices.
9. Equatorial or more posterior lattices

Identifying LD...
Novices confuse it with Ora sometimes.
(Trace all its borders).
For LD, lattice (white criss-cross) lines are
NOT must (rather lesions may have
pigmentation/whitish flecks/ red
craters/snow flakes or RPE atrophic spots
along with retinal thinning; However its
borders are SHARPLY demarcated
(abruptly ending) from surrounding normal
retina.
If treating LD, surround by 3 rows of laser
spots especially anterior margins.

Tip-60....
Majority of Intraocular malignancies are
metastatic (majority to choroid, being highly
vascular, usually non-pigmented & poorly
circumscribed with/out exudative RD) most
of which ophthalmologists never come to
see.
Breast CA (carcinoma) metastasis
(commonest in females) tends to be B/L &
multifocal, while Lung CA (commonest in
males) metastasis tends to be U/L &
Unifocal.

Tip-61.....
ALWAYS think of 5 following retinal
diseases other than AMD in a patient with

Macular hges, edema & subretinal
exudates....
Abbreviated by an Acronym- MICRA....
1. Macroaneurysm (RAM)
2. IPCV
3. CNVM ((idiopathic)
4. RAP (Retinal Angiomatous Proliferation)
in MacTel/PFT.
5. Adult Coats‟

Tip-62.....
Hard & Soft Facts about Drusen (D)...
-Hallmark of Dry (Non-exudative) AMD &
are degenerated RPE products?
-Sub-RPE or Intra-Bruch‟s pale yellow
deposits
-could be Small/hard(<63mn), medium or
Large/Soft (>125mn)
-Calcified D. are yellow & glistening
-„Large/soft D & Focal hyperpigmentation‟
of RPE form risk factor (& not small/hard
D) for CNVM, hence need AREDS2
formula (reduces risk of advanced ie
Geographic & Neovascular AMD by 25%
over 5 years) orally.
-Usually asymptomatic or may cause
impaired contrast/distortion/ poor light
adaptation/ reading difficulty.
-May resolve or increase (ie NOT static)
-Large/soft D may confluend causing
Drusenoid PED.

-FFA- Hard D: Early Hyperfluorescence due
to overlying RPE atrophy, while soft show
early hypo & late hyperfluorescence. No
leaks.
-Intermediate AMD is Medium D with RPE
alterations or 1 or more Large D.

Tip-63.....
Most closely mimicking disease of Diabetic
retinopathy is „Radiation Retinopathy‟ (RR)
which has exactly similar fundus picture.
RR....
-Usually delayed by 6-36 months of
unshielded radiation (external beam or
plaque brachytherapy)
->5000 rad (50 Gray) is most offending
((although no definite value can be given).
-Commonly after CA nasopharynx, Pituitary
tumor, etc
-Walls of capillaries & small vessels of
retina get damaged.
-Treatment similar to DR viz. Laser & Anti-
VEGF.
Radiation optic neuropathy occurs with
similar doses & is similarly delayed, while
Cataract occurs more frequently, early &
with lesser doses (500 rads).

Tip-64......
Treatment of Age-related Macular
Degeneration (AMD)....

1. Dry (Non exudative) with Hard/small
druse & non-geographic or geographic
atrophy- No role of AREDS2 formula. Stop
smoking. Control weight & HT. Issue Grid.
2. Intermediate AMD (Medium druse +
focal hyperpigmentation or 1 or more
soft/large drusen (>125 mn) - Give AREDS-
2 formula drug.
3. Wet (Exudative) AMD- Monthly
Ranibizumab (US-FDA approved)
/Bevacizumab (off-label) or Bimonthly
Eylea.
Thermal Laser for extrafoveal CNVM (as
per MPS of 1980). 60% recurrence (hence
many prefer Anti-VEGF).
PDT- presently used only as adjunct (with
reduced fluence/energy) with Anti-VEGF.
Works best for PCV.
Submacular hge- poor results with surgical
evacuation. Pneumatic displacement + TPA
(Tissue plasminogen activator) inj. (lyses
clot) may help.

Tip-65......
As per SUN (Standardisation of Uveitis
Nomenclature, 2004) by IUSG
(International Uveitis Study Group)-
Intermediate uveitis (IU) is Vitritis with
peripheral retinal vascular sheathing or/&
macular edema due to any cause (vide infra).
While Pars planitis (PP, constitutes 70% of

all IU) is a specific, idiopathic (NOT
secondary to any systemic/ocular disease)
type of IU with Snowballs in inferior
peripheral vitreous or Snow-banking on
inferior peripheral retina (both are
manifestations of inflammation)
Acronym for known causes of IU- SMILE....
Sarcoidosis, Multiple sclerosis,
Inflammatory bowel disease, Lymphoma
(2/3rd primarily from CNS), Etc (includes
TB, Toxocara, etc.). Sarcoidosis, PP & TB
are most important.
Treatment for Pars Planitis required (in
70%) only if associated with Macular edema
(occurs in 50%) causing diminution of
vision or Peripheral retinal
neovascularisation. Treatment includes....
1. Periocular steroids -mostly subtenon
Tricort/Triamcinolone acetonide 0.5-1 ml of
40mg/ml. Repeat at 6 weeks. Check for
steroid responder- Prednisolone drops qid x
2-3 weeks (Not confirmatory).
2. Systemic steroids- if PP is B/L & severe.
1-1.5 mg/kg/day Predni x 4 weeks. Taper as
per response.
3. Intravitreal steroid implant- Ozurdex (0.7
mg Dexamethasone)/Allergan/ INR 26,000/
(MRP-36000/)
4. Immunosuppressives- Methotrexate safest
(even in child) & most tried. Cyclosporine
next alternative.

5. Laser (Cryo, only if Laser not possible)
for peripheral neovascularisation.

Tip-66......
CSC/CSR has been strongly associated with
use of steroids, even if given in the form of
skin creams, inhalers, joint injections, oral
or parenteral. It must be discontinued.

Tip-67.....
Spectralis (HRA) & Optos use Confocal
scanning laser ophthalmoscope (CSLO),
providing high resolution fundus images,
unlike conventional Fundus cameras.
CSLO uses Diode laser beam scanning in
Raster (transverse) fashion & improves
patient‟s comfort also by using less bright
light.
Confocal imaging is enface
(frontal/transverse) imaging at one plane
eliminating background information which
otherwise degrades the image.
Both Spectralis & Optos also provide
Multimodal fundal imaging (MMFI).
MMFI is combining different imaging
modules to diagnose or manage single
retinal disease & may include....
Fundus photography, Wide field &
Ultrawide field imaging, Red free, Stereo
photography, Infrared reflectance, FFA,
FAF, ICG, SD-OCT, SS-OCT, EDI-OCT,

OCTA & Adaptive optics SLO.
Blue colour photography is best for retinal
surface (ERM, RNFL), Green for hges &
Infrared (less absorbed by blood & pigment)
for RPE & Choroid.

Tip-68.....
Posterior segment/ Macular evaluation in
Cataract patient....
Especially if vision (after best correction)
not COMMENSURATE with cataract &
Fundus examination is difficult....
-Accurate PL & PR. Check for yourself.
-Try I/O (brighter light)
-Pupillary reactions
-Maddox Rod (MR)-patient looks at
penlight at 1 foot through MR. Reports
break/distortion.
-Laser Interferometry-Fringes projected
through clear area. Overestimates vision,
especially in amblyopes.
-Entoptic phenomena (Purkinje)- penlight is
rapidly moved on closed lids creating
Fundal vascular tree perceived by patient.
-Potential visual Acuity Meter (PAM)-
Miniature Snellen chart is projected on the
macula.
-VEP- Amplitude is for macula/ visual
acuity & Latency is for Visual pathway
(includes optic nerve)

-USG-B scan
-Focal ERG
-OCT rarely feasible.
MR, LI, PAM & Entoptic are Subjective &
need some clear area in cataract.

Tip-69.....
Classical presentation of Ocular
Toxoplasmosis (OT) is active chorioretinitis
(necrotising) adjacent to healed pigmented
scar (punched out) with (may be absent in
immunocompromised) overlying vitritis
„Headlight in fog appearance‟.
Facts about OT...
-most common cause of posterior &
infectious uveitis.
-Now acquired infection considered equally
important (earlier always believed to be
reactivation of congenital focus)
-commonly asymptomatic (peripheral, self-
limited, requiring no treatment)
-Granulomatous or non-granulomatous &
Recurring (especially in first year).
-Any positive titre of Antibody is useful.
Negative titres rule it out (exception-
immunocompromised). IgM titre indicates
recent infection. PCR also available for
aqueous/vitreous tap.
-Treatment required only if fovea, large
retinal vessel (occlusion/hge) or optic nerve
threatened or already involved actively or

immunocompromised or if patient is child.
-Triple therapy of SPP- Sulfadiazine+
Pyrimethamine+ oral Predni is best. Folinic
acid added to counteract side effect of
Pyrimethamine.
-Alternately Tab Cotrimoxazole
(Trimethoprim+ Sulfamethoxazole) 2BD x
4-6 weeks (especially used to prevent
recurrences)
-Clindamycin for Sulfa allergic patients.

Tip-70......
In contrast to Ocular Toxoplasmosis (OTP),
another vitreo-retinal disease (less common)
is Ocular Toxocariasis (OTC). (See Tip-69)
OTC unlike OTP is/has....
-Always unilateral
-Always acquired (Feco-oral from cat/dog
feces). Usually children.
-More often peripheral retina involved
-Non-necrotising, granulomatous,
FIBROTIC disease (vitreous membranes &
tractional RD)
-Chronic “pseudo-endophthalmitis” picture
may present as Leucocoria (Pseudoglioma).
-Diagnosis mainly clinical or ELISA for Ab.
Eosinophilia in Systemic Toxocariasis
(Visceral Larva Migrans/VLM).
-Treatment- Steroids (for active vitritis) &
Surgery (PPV to remove membranes &
traction) are the mainstay.

Tip-71......
Epiretinal membrane (ERM).....
-Synonyms- Cellophane maculopathy,
Surface wrinkling retinopathy or Macular
pucker.
-Commonly idiopathic (after 60 years) or
Secondary to many Retinal diseases
-1/5th are B/L
-Starts with PVD & ILM disruption
stimulating Glial (Muller) cells causing
Fibro-cellular (but Avascular) proliferations.
-Asymptomatic, if thin, as in majority.
-Appears as translucent, shiny macular
surface on 90D exam when young, but
gradually opacifies.
-May cause CME, TRD or Spontaneous
RELEASE (resolution).
-OCT is Gold standard for diagnosis,
progress & prognosis. To differentiate from
PVD on OCT-
Unlike ERM, PVD is usually greatly
separated from retina & is thin, patchy &
less reflecting.
-Surgery- PPV with peeling & removal if
VA is less than or equal to 6/18 or
disturbing metamorphopsia present. Expect
improvement over 3-6 months if not long-
standing & Ellipsoid layer is intact on OCT.
Recurs in 1%.

Tip-72......
Meaning of Zumab in
Ranibizumab/Bevacizumab.....
MAB is an acronym for Monoclonal
antibodies (derived from a single B-cell
clone)
Depending upon the source of mAb, WHO
has given uniform generic nomenclature
(2009)....
-Zu... Humanized i.e. Ab generated from
genome of non-human species, modified to
produce matching natural human antibodies.
-Xi... Chimeric (animal) origin
-U... Human source of genome (injected into
mice to produce Ab)
-O... Murine (mice) source

Tip-73.....
Tips for Indirect Ophthalmoscopy (I/O).....
-Use minimum usable light & start with
superior periphery (let patient acclimatise to
light).
-Use small spot size for small pupil & vice
versa.
-Remember, although image we see in the
lens is laterally & vertically inverted eg if
seeing superiorly, image of peripheral retina
is seen inferiorly in the field of the lens. But
clock hour of retina remains the same eg
patient looking superiorly means superior